For best results, please fill this form out on desktop or laptop instead of a mobile device. Intake Form "*" indicates required fields Step 1 of 6 16% Your Child's Safety is Our Top Priority In order to ensure the safety of your child during his/her in-home therapy session, it's imperative that an adult be present in your household at all times. While it's not mandatory that a parent/caregiver join the actual session, it can be beneficial. Note: This form provides developmental milestones and information necessary to better understand your child as we move forward.Patient InfoPatient Name* First Last Nickname DOB* MM slash DD slash YYYY Sex* Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Apartment # Name of Apartment Complex or Sub-division Access/Gate Code License and InsuranceHow would you like to share your License and Insurance information? Upload Email Upload a digital copy of your Insurance and License*You may upload digital copies of the front and back of your insurance card and license here. Allowed files: PDF, Word Docs, JPG, & PNG. *IMPORTANT: when uploading files, a red X will appear next to your file. This does not mean an error. The X is to remove the file you uploaded in case you upload the wrong file by mistake. PLEASE ALSO ENTER YOUR INSURANCE CARD DETAILS IN THE INSURANCE SECTION BELOW Drop files here or Select files Accepted file types: doc, docx, jpg, jpeg, pdf, png, Max. file size: 100 MB. Send a digital copy of your Insurance and License to: [email protected]Will therapy need to be conducted outside the home?*I travel to your child at the parent/guardian home. Is there an alternate location outside the home to visit? Eg, daycare, babysitters, church, preschool program? Yes No Name of Alternate Location* Contact Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Referral QuestionsReason for Requesting Services*Your Child's Specific Diagnosis How did you learn about Advantage Speech Therapy Services? Friend Doctor Therapist Other Who can we thank for their recommendation? Parent/Caregiver InfoParent/Caregiver Name (#1)* Relationship to Child DOB* MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Alternate PhoneAlternate Phone Type Work Cell Home Email What is the best form of communication to reach you?*(Check all that apply) Text Cell Email Select AllEmployment Info #1 Stay at Home Parent Employed Unemployed Is there a second Parent/Caregiver? Yes No Employer Info (#1)Employer Name* Position Work Phone*Work Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Caregiver Info (#2)Parent/Caregiver Name (#2) Relationship to Child DOB MM slash DD slash YYYY Same address as Parent/Caregiver #1? Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Alternate PhoneAlternate Phone Type Work Cell Home Email What is the best form of communication to reach you?*(Check all that apply) Text Cell Email Select AllEmployment Info #2 Stay at Home Parent Employed Unemployed Employer Info (#2)Employer Name* Position Work Phone*Work Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code MedicalPediatrician/Primary Doctor Name* Phone*FaxAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code TeletherapyTeletherapy?* Yes No Private Pay?* Yes No InsurancePrimary Insurance* DOB* MM slash DD slash YYYY Group # Subscriber’s ID HiddenSubscriber’s ID Subscriber’s Name Relationship to Child PhoneSecondary Insurance Available?* Yes No Secondary Insurance DOB* MM slash DD slash YYYY Group # Subscriber's ID Subscriber’s Name: Relationship to Child Phone Family MembersUse the + symbol to add additional rows for parent(s)/sibling(s).Use the + symbol to add additional rows for parent(s)/sibling(s).ParentsBrothers & AgesSisters & Ages Add RemovePlease list & describe any Family Members with a history of......a known speech, language, fluency and/or hearing concernIs your child bilingual? Yes No What language(s) are spoken in the home? Child's primary language? Child's secondary language? Child's Communication StylePlease describe your child's difficulty with communicating and how it impacts his/her daily activitiesHow does your child typically communicate? How does your child express his/her wants and needs?Check the ones that apply. Gesture Sign Language Grunting Talking (select all that apply below:) Pointing/Pulling Talking Styles... Jargon/Unintelligible Speech Single Words Word Combinations Is your child aware of their difficulty in communicating? Yes No How does it impact him/her?How would you describe your child's ability to speak clearly? In error, but understandable Difficult to understand Requires careful listening I don't understand much of what he/she says Other Can an unfamiliar listener understand him/her? Yes No Does their teacher have trouble understanding him/her? Yes No What % do you as the caregiver understand him/her? Which caregiver are you? Mom Dad Other At what age did your child stop using the pacifier? At what age did your child stop drinking form a bottle? Has your child been in therapy before? Yes No Specify the Discipline(s)OT, Speech, PT, ABA or Other When and with whom did they see?Has your child had a speech evaluation? Yes No Date of Speech Evaluation MM slash DD slash YYYY Does your child receive speech in the school? Yes No Do they have an active IEP?* Yes No Do you have a copy of their IEP to provide ASTS?* Yes No I understand that ASTS will need a copy before therapy can be provided.* I understand and acknowledge this requirement. What goals did they address?(Examples may include: walking, talking, sensory motor, behavior, language) Medical History/MilestonesHow was the child's mother's health during pregnancy?Any complications during birth? Yes No Describe anything unusual during or immediately following the birthHas your child been hospitalized? Yes No What was the reason?Does your child take any medication? Yes No Please list medication and reasonDoes your child have difficulty eating? Yes No Please describe their difficulty with eating.How does your child get along with other children and/or siblings? At what age did your child... (Please indicate year or month. E.g., 1 year, 7 months, 1 yr 3 mos, etc.)Crawl Babble Dress self Sit Use first word Use toilet Stand Use 2+ words Feed self Walk When was the most recent hearing screening and/or evaluation? MM slash DD slash YYYY Who conducted the test? Please specify the doctor. What were the results? Did your child receive tubes in his/her ears? Yes No When? MM slash DD slash YYYY Additional InfoWhat activities does your child enjoy participating in?What frustrates your child?What are his/her strengths?What are his/her weaknesses?What would you most like to see your child gain from speech therapy?Does your child have any known food (or other) allergies?If so, please specify.Additional comments:CAPTCHAGet a PDF copy of this form emailed to you.Let us know which email to send a PDF of this form to. Enter Email Confirm Email Thank you for taking the time to help us understand your child’s family/medical history, and developmental level.This information will help us appreciate your child’s strengths and weaknesses in order to address specific goals to increase their communication skills!PhoneThis field is for validation purposes and should be left unchanged.
